59 y.o. man: acute back pain Leaking AAA s/p EVAR

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Presentation transcript:

59 y.o. man: acute back pain Leaking AAA s/p EVAR EVAR Endoleaks – RAML 1.31.17 59 y.o. man: acute back pain 11/7/15 CTA: AAA 6cm, with leak and retroperitoneal hematoma 11/9/15 CTA: 2D s/p Endologix stent-graft repair: short bifurcated body, two proximal sleeves Leaking AAA s/p EVAR

Surveillance missed. 13 mos. later: acute back pain EVAR Endoleaks – RAML 1.31.17 Surveillance missed. 13 mos. later: acute back pain 12/8/16 CTA: Type 3 endoleak and acute sac rupture main body angulated in relation to and separated from proximal components proximal components slipped distally into sac

EVAR Endoleaks EVAR stent-grafts EVAR Endoleaks – RAML 1.31.17 EVAR Endoleaks EVAR stent-grafts purpose: exclude pressure from aneurysm sac, maintain distal flow. design: self-expanding stents outwardly press microporous fabric against atherosclerotic aortic and iliac walls, and sac thrombus. materials: push limits of stent and fabric thickness/strength vs. delivery size. procedure: unlike open graft, no opportunity to ligate or reimplant side branches (lumbar arteries, IMA). after aneurysm exclusion: sac thrombus matures, reconfigures, hemolyzes. these principles provide the opportunities for failure (endoleaks) and the requirement for lifelong imaging surveillance. Endoleaks: classify them with imaging to understand their mechanism, and thus, the urgency and type of repair.

Endoleak Classification EVAR Endoleaks – RAML 1.31.17 Endoleak Classification Type 1: proximal or distal seals fail: high-pressure leak: URGENT REPAIR 1-month post-op: limb attachment leak: Rx covered stent

Endoleak Classification EVAR Endoleaks – RAML 1.31.17 Endoleak Classification Type 2: aortic side branches reconstitute flow in sac: lumbars, IMA low-pressure leak: FOLLOW SAC SIZE embolize electively if leak persistent AND sac enlarging

Endoleak Classification EVAR Endoleaks – RAML 1.31.17 Endoleak Classification Type 3: graft disruption: fabric tear, component separation high-pressure leak: URGENT REPAIR

Endoleak Classification EVAR Endoleaks – RAML 1.31.17 Endoleak Classification Type 4: porous fabric: usually seen while still anticoagulated postop. low-pressure leak: await reversal of anticoagulation. Type 5: “endotension”: sac growth in the absence of a visible leak. low-pressure leak: re-line stent-graft electively if sac enlarging

EVAR Endoleaks – RAML 1.31.17 Summary Endoleaks: classify them with imaging to understand their mechanism, and thus, the urgency and type of repair. High-pressure leaks: URGENT repair with covered stents Type 1: proximal or distal seals fail Type 3: graft disruption: fabric tear, component separation Low-pressure leaks: treat electively if sac enlarging Type 2: aortic side branches reconstitute flow in sac: lumbars, IMA Type 4: porous fabric: usually seen while still anticoagulated postop Type 5: “endotension”: sac growth in the absence of a visible leak Radiology 2007;243:641-655. AJR 2009:192:W178-W186)